Conscious: Acute Coronary

Syndrome (ACS)

UAP & NSTEMI
Unstable angina, at least one of three features:
1. Occurs at rest (or w/ minimal exertion, lasting > 10
2. Severe & of new onset (within the prior 4-6 weeks)
3. Occurs with a crescendo pattern (more severe,
prolonged, or frequent)

Non-ST-segment elevation myocardial infarction: +
evidence of myocardial necrosis cardiac
biomarkers.
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Pathophysiology
1. Plaque rupture/erosion with a superimposed
nonocclusive thrombus downstream
embolization
2. Dynamic obstruction (coronary spasm, PVA)
3. Progressive mechanical obstruction
(atherosclerosis)
4. UA secondary to increased myocardial O
2

demand/decreased supply (tachycardia, anemia)

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Clinical Presentation
History & Physical Examination
Chest pain substernal, epigastrium neck, left
shoulder, left arm.
Anginal equivalents: dyspnea, epigastric discomfort
Large area of myocardial ischemia: diaphoresis, pale-
cool skin, sinus tachycardia, a third/fourth heart sound,
basilar rales, hypotension resembling large STEMI.
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Pathophysiology: plaque rupture accompanied by
thrombus formation & vasospasm (intracoronary)
ECG: T wave & ST segment changes.
CHARACTERISTIC MORE LIKELY TO BE ANGINA LESS LIKELY TO BE ANGINA
Type of pain Dull, pressure Sharp, stabbing
Duration 2-5 min, always < 15-20 min Seconds or hours
Onset Gradual Rapid
Location Substernal Lateral chest wall, back
Reproducible With exertion With inspiration
Associated
symptoms
Present Absent
Palpation of chest
wall
Not painful Painful, exactly reproduces pain
complaint
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Electrocardiogram
UA: ST-segment depression, transient ST-segment
elevation, T-wave inversion

Cardiac Biomarkers
biomarkers of necrosis (CK-MB, troponin) risk
for death or recurrent MI NSTEMI.
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Diagnostic Evaluation

Algorithm for risk stratification and treatment of patients with suspected coronary artery disease.
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Risk Stratification & Prognosis

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Treatment
Medical treatment
Bed rest
Continuous ECG monitoring: ST deviation & arrhythmias
Anti-ischemic treatment
To provide relief and prevention of recurrence of chest
pain, initial treatment should include bed rest, nitrates,
and beta blockers.
Antithrombotic treatment
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ACC/AHA 2011 Guidelines for the Management of Patients With UA/NSTEMI

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ACC/AHA 2011 Guidelines for the Management of Patients With UA/NSTEMI
STEMI
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cigarette smoking
hypertension
lipid accumulation
atherosclerosis
coronary blood flow decreases abruptly
coronary emboli
congenital abnormalities
coronary spasm
systemic inflammatory diseases
STEMI
Etiology:
Clinical Presentation
Precipitating factor: vigorous physical exercise, emotional
stress, medical/surgical illness.
Pain: deep & visceral, heavy, squeezing, crushing, involves
the central portion of the chest/epigastrium, sometimes
radiates to the arms, abdomen, back, lower jaw, neck.
Weakness, sweating, nausea, vomiting, anxiety, sense of
impending doom.
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Physical findings:
Anxious & restless
Substernal chest pain > 30 + diaphoresis
Sympathetic nervous system hyperactivity (anterior infarction);
parasympathetic hyperactivity (inferior infarction)
Precordium is usually quiet, apical impulse difficult to palpate
Ventricular dysfunction, murmur
carotid pulse volume stroke volume

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Laboratory Findings
ECG
Initial stage: total occlusion ST-segment elevation
Most patients ultimately evolve Q waves
Serum cardiac biomarkers
Cardiac-specific troponin T (cTnT) & cardiac-specific
troponin I (cTnI) may remain elevated for 7-10 days.
Creatinine phosphokinase (CKMB) rises within 4-8 h,
returns to normal by 48-72 h.
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Cardiac imaging
Two-dimensional echocardiography wall motion
abnormalities
Radionuclide imaging techniques
High-resolution cardiac MRI
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Initial Management
Major elements of prehospital care:
1. Recognition of symptoms & seeking of medical
attention
2. Rapid deployment of an emergency medical team
capable of performing resuscitative maneuvers
3. Expeditious transportation to a hospital facility skilled
in managing arrhythmias & providing ACLS
4. Expeditious implementation of reperfusion therapy
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Management in the ED
GOALS ACTIONS/MEDICATIONS
1. Control of cardiac discomfort Nitroglycerin, morphine, beta blockers
2. Rapid identification of patients
who are candidates for urgent
reperfusion therapy
ECG
Reperfusion therapy: ST-segment
elevation 2 mm in 2 contiguous
precordial leads and 1 mm in 2 adjacent
limb leads is present.
3. Triage of lower-risk patients to the
appropriate location in the hospital
4. Avoidance of inappropriate
discharge of patients with STEMI
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Reperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred
strategies.
OGara P T et al. Circulation 2013;127:529-555
Copyright American Heart Association
Primary PCI in STEMI
ACC/AHA 201 Guidelines for the Management of ST-Elevation Myocardial Infarction
ACUTE MYOCARDIAL
INFARCTION
Acute, evolving, or recent MI:
1. Typical rise & gradual fall (troponin) or more rapid
rise & fall (isoenzyme of creatine kinase with
muscle & brain subunits [CK-MB]) of biochemical
markers of myocardial necrosis with at least one:
a. Ischemic symptoms
b. Development of pathologic Q waves on the ECG
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c. ECG changes indicative of ischemia (T wave changes or
ST segment elevation or depression)
d. Coronary artery intervention
2. Pathologic findings of an AMI.

Established MI:
1. Development of new pathologic Q waves on
serial ECGs
2. Pathologic findings of a healed or healing MI.
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Symptoms:
TYPICAL ATYPICAL
Chest pain Dyspnea
Syncope
Confusion
Stroke
Fatigue
Nausea/emesis
Sudden death

Giddiness
Diaphoresis
Arterial embolus
Palpitation
Renal failure
Pulmonary
embolus

Restlessness
Abdominal pain
Arm pain only
Cough
Silent (-)
No symptoms (-)
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